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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1367_Библиотеки_им_академика_М_И_Перельмана
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6 Kent, Port, and Altorki
Fig. 1. Endoscopic view of an esophageal tumor.
Fig. 2. Endoscopic ultrasound image of an esophageal tumor invading the muscular wall of the
esophagus.
enopathy (Fig. 2). EUS can also allow for fine-needle aspiration of these lymph nodes.
Finally, some groups have advocated more invasive methods of staging such as thora-
Chapter 1 / Esophagectomy and Reconstruction 7
coscopy and laparoscopy (17). Although these procedures are clearly sensitive for detecting extra-esophageal disease, it is not clear how much additional information is
provided compared with standard modalities such as EUS and CT scanning.
TREATMENT
Surgery, radiation therapy, and chemotherapy, either alone or in combination, have
all been claimed as standard therapy of esophageal carcinoma. In part, this controversy
stems from the generally poor outcome of any treatment modality. Although most surgical series studies report 5-yr survival rates of only 25%, esophagectomy is nonetheless
considered to offer the best potential for cure. Recently, several randomized, controlled
clinical trials have evaluated whether the addition of chemotherapy and radiation therapy
to surgery offers any benefit. No study to date has supported the use of either of these
modalities alone (18,19). However, the utility of combined induction chemoradiation is
more controversial. Several small single-arm series has shown benefit for this approach
compared with historical controls (20,21). However, three large, randomized trials have
reported mixed results (Table 1) (22–24). Of these three, only one study demonstrated
a statistically significant difference in survival with induction chemoradiation compared
with surgery alone (24). This study has been criticized for the unusually poor survival
rate (6%) in the surgical arm. To date, therefore, we consider surgical resection alone to
be the standard of care for patients who are acceptable candidates.
As with nonoperative therapy, the surgical options for management of esophageal
cancer are numerous. The two approaches most commonly used are the transthoracic
(TTE) and the transhiatal esophagectomy (THE). The TTE exposes the esophagus
through either a right or left thoracotomy, depending on the location of the tumor and the
preference of the surgeon. In general, tumors of the distal third of the esophagus are best
exposed through a left thoracotomy, those of the middle- and upper-third through a right
thoracotomy. Regardless of the exposure, the principles of the operation do not differ:
mobilization and resection of the involved esophagus with adequate margins, removal
of adjacent lymph nodes, and the restoration of continuity of the GI tract. The esophagus
must be completely mobilized from the diaphragmatic hiatus to the thoracic inlet to
permit safe resection. Although tissue bearing lymph nodes is removed with the specimen, a meticulous lymph node dissection is not part of the standard esophagectomy. To
restore continuity of the GI tract, a substitute for the esophagus must be found. Most
commonly, the organ used for this purpose is the stomach. To do this, the stomach must
be freed from its peritoneal attachments. If a left thoracotomy is used, the stomach may
be exposed and mobilized through an incision in the diaphragm. If a right thoracotomy
has been chosen, an additional upper abdominal incision will also be necessary. The
greater curvature of the stomach is then freed from the omentum. A stapler is then fired
across the lesser curve, in order to fashion the stomach into a tube appropriate for
anastomosis with the remaining esophagus (Fig. 3A).
The vascular supply of this gastric tube is based on the right gastroepiploic artery,
which must be preserved during mobilization of the stomach. Finally, the prepared
gastric tube is then passed under the aortic arch and attached to the esophageal stump.
Typically, the esophageal anastomosis is located within the mediastinum. However, a
separate incision may be made in the neck to fashion a cervical anastomosis.
The transhiatal esophagectomy (THE) has become a popular alternative to a TTE, in
part based on the belief that many potential complications are avoided by not entering
Table 1
Randomized Trials of Chemoradiotherapy Followed by Surgery Compared to Surgery
Operative Complete
No. of TR dose mortality Pathologic Mediam Survival
Author Patients (GY) Chemotherapy (%) Response Time (YR) Survival rate (%)
8 Kent, Port, and Altorki
8
Urba et al. (1997) 100 45 CDDP-BL-VBL Surg-NS NS NS 33 (3 yr)
CRT-NS NS NS 18 (3 yr)
Walsh et al. (1996) 113 40 CDDP-FU Surg-3.6 — 11 32 (3 yr)
CRT-8.6 25% 6 6 (3 yr)
Bosset et al. (1997) 297 18.5 CDDP Surg-3.6 — 18.6 38 (3 yr)
CRT 12.3 26% 18.6 38 (3 yr)
Abbreviations: CDDP = cis- platinum, FU = 5- fluorouracil, BL = bleomycin, VBL = binblastine, NS = not stated, Surg = surgical arm, CRT
= chemotherapy radiotherapy plus surgery arm, CT = chemotheraphy, TR = total radiation.
Chapter 1 / Esophagectomy and Reconstruction 9
Fig. 3. (A) Gastric pull-up. (B) Colonic transposition (Adapted from Shackelford’s Surgery of
the Alimentary Tract, Volume I, Fifth Edition, WB Saunders, 2002).
the chest. THE differs from TTE in two important respects. First, the thoracic esophagus
is entirely mobilized through the hiatus of the diaphragm, without the need for a thoracotomy incision. Second, the tubularized stomach is brought up into the neck where a
cervical anastomosis is preformed. Proponents of this approach report decreased pain
and pulmonary complications by avoiding a thoracotomy. In addition, an anastomotic
leak within the neck is much easier to manage. Usually, the incision can be opened at the
bedside and the leak safely drained. In contrast, a mediastinal leak carries a 50% mortality and often requires operative reexploration and possible takedown of the anastomosis. Critics of THE note that the operation affords a less-complete lymphadenectomy. In
addition, the leak rate from a THE may be slightly higher, because the stomach must be
mobilized further and the anastomosis carried higher than for a TTE. However, in the
hands of qualified esophageal surgeons, the operative approaches are essentially equivalent. The operative mortality, incidence of complications, and length of stay have never
been shown to differ between these operations. Furthermore, and most importantly, the
5-yr survival following a standard esophagectomy is a consistent 25%, whether the
approach be transthoracic or transhiatal (25,26).
Several modifications have been proposed to improve the disappointing cure rate
of a standard esophagectomy. An en bloc esophagectomy offers to the esophageal
surgeon what is a standard principle to other surgical oncologists: removal of the
10 Kent, Port, and Altorki
involved organ with an envelope of adjoining normal tissue. This envelope of normal
tissue should include the posterior pericardium, both pleural surfaces where they abut
the esophagus, and the lymphovascular tissue between the esophagus and the spine.
The deep location of the esophagus within the mediastinum, however, makes this a
more challenging operation.
The evolution of a more formal lymph node dissection represents a further refinement
in esophageal surgery. The basis for this stems from the distribution of lymphatic drainage within the esophagus. Unlike other organs of the gastrointestinal tract, the abundant
lymphatic channels of the esophagus course longitudinally within the submucosa of the
esophagus for long distances before draining to adjacent lymph nodes. However, in a
standard esophagectomy, little attempt is made to remove any lymphatic tissue distant
from the primary tumor. Perhaps, this in part explains the disappointing local recurrence
rates (20–60%) following the standard operation. In a “two-field lymphadenectomy,”
the standard operation is modified to include the systematic removal of middle and lower
mediastinal nodes (periesophageal, parahiatal, subcarinal, and aortopulmonary) and
upper abdominal nodes (those adjacent to the celiac axis, and splenic, left gastric, and
common hepatic arteries). An overall disease-free survival of 40% was achieved at our
center in esophageal cancer patients resected with a combined en bloc, two-field lymphadenectomy (Fig. 4).
A “three-field lymphadenectomy” extends the lymph node dissection to include the
lymph nodes within superior mediastinum, located along the course of the left and right
recurrent laryngeal nerves. The rationale for extension of the lymph node dissection is
based on the finding that nearly one-third of patients with presumably localized esophageal cancer have occult metastases to these nodes. Recent reports both in our center and
in Japan have confirmed this finding, particularly in patients with adenocarcinoma of the
esophagus. In addition, we have shown that the procedure may be conducted with a
mortality and morbidity comparable to the “two-field” lymphadenectomy. Significantly,
our long-term survival with this approach demonstrates a significant survival advantage
over the standard esophagectomy and two-field lymphadenectomy (27,28). Unfortunately, lack of familiarity with this approach has limited its performance to a few specialized centers in Japan and the United States.
For those patients who are not candidates for curative esophagectomy, other options
for palliation may be offered. Primary chemoradiation has been shown to produce 5-yr
survival rates as high as 10%, and should be considered for the majority of patients whose
cancer is unresectable. Esophageal dilatation offers short-term palliation, although the
risk of esophageal perforation is not insignificant. Stenting or laser fulguration may also
offer symptomatic relief in patients with a limited life expectancy. It should be emphasized that although esophagectomy offers excellent palliation of symptoms, patients
should not be offered surgery without curative intent.
OPTIONS FOR ESOPHAGEAL RECONSTRUCTION
Restoration of continuity of the GI tract is most commonly performed with a portion
of tubularized stomach. However, other options for reconstruction are available to the
esophageal surgeon. For instance, colonic interposition may be offered to patients
undergoing esophagectomy for benign disease. Interposition of colon offers several
potential benefits: an organ with potentially functional peristalsis and an epithelium
Chapter 1 / Esophagectomy and Reconstruction 11
Fig. 4. Overall survival of patients treated with an en bloc esophagectomy at Weill-Cornell
Medical Center.
relatively impervious to acid reflux, a conduit of nearly unlimited length, and the ability
to place the conduit in a location other than the posterior mediastinum. In addition, the
vascular supply to the colon is abundant and well described. For malignant disease, the
gastric pull-up is the preferred method for reconstruction. The use of stomach is technically straightforward and requires only one anastomosis. However, in situations in
which prior gastric surgery has rendered the stomach unsuitable, colon interposition is
an acceptable alternative. Some centers routinely use colon interposition for reconstruction after esophagectomy for benign disease. This practice is based on the belief
that the development of anastomotic stricture and acid reflux may be less after colon
interposition. No long-term studies have demonstrated the superiority of colon interposition over gastric pull-up. Furthermore, the necessity of additional abdominal surgery
and a second anastomosis increases the complexity of an already demanding operation.
Nonetheless, several large series have demonstrated the safety of this procedure in
experienced hands (29,30).
Colonoscopy is required for preoperative evaluation of patients undergoing colonic
interposition. Occasionally, the findings of polyps or occult malignancy will preclude the
use of colon. Although angiography had once been considered mandatory, it is currently
reserved for patients with significant vascular disease or those with a history of prior
colonic surgery. Although either the left or right colon may be used for reconstruction, the
left colon is by far the better alternative for several reasons. First, the smaller diameter of
the left colon provides for a technically easier anastomosis to the proximal esophagus.
Also, the blood supply to the left colon is less variable than that of the right colon. Finally,
the left colon may be placed in the thorax in an isoperistaltic direction.
To perform a left colon interposition, the descending and transverse colon are mobi-
lized. This may be performed through either a laparotomy or an incision in the diaphragm
if a left thoracotomy has already been performed. The vascular supply to the left colon
12 Kent, Port, and Altorki
is identified including the marginal artery of Drummond, the left and right branches of
the middle colic artery and the ascending and descending branches of the left colic artery.
Adequate blood supply is determined by transillumination of the mesentery and palpation of a pulse. Once the appropriate length of conduit has been determined, temporary
vascular clamps are placed on the vessels to be ligated. The viability of the bowel is then
reassessed by visual examination. On occasion, intravenous fluoroscein may be useful
if the viability of the conduit is in question. For long segment interposition, the vascular
supply is based on the left colic artery. The colon is then divided distal to the splenic
flexure distally and at the mid-transverse colon proximally. If additional length is
required, the colon may be transected near the hepatic flexure. The colon is then mobilized through the lesser sac behind the stomach and brought into the chest through the
esophageal hiatus. Anastamoses are then constructed to the proximal stomach and posterior wall of the stomach (Fig. 3B). Great care must be exercised to ensure that the
vascular pedicle is not disrupted during mobilization to the chest. Graft ischemia may
readily occur if the anastomosis is placed under tension or if the pedicle is rotated.
Venous drainage from the colon is as important as arterial supply and may be easily
compromised if the pedicle has been rotated.
Interposition of jejunum may also be considered for short segment replacement of the
esophagus. The variable blood supply to the jejunum mandates careful evaluation of the
intestine prior to transfer. Congenital interruptions in the vascular arcade occur frequently and must be excluded before a segment of jejunum can be considered suitable.
The dissection is usually begun at least 20 cm distal to the ligament of Treitz, at which
point the vascular branches are longer and an appropriate pedicle may be identified
more easily. Free jejunal transfer with construction of a microvascular anastomosis to
the common carotid artery has been described for replacement of a short segment of
the cervical esophagus (30).
MANAGEMENT OF COMPLICATIONS
Even in the most experienced hands, an esophagectomy is a complex procedure that
carries a consistent mortality of 5% and a complication rate of 40%. Complications
common to all lengthy operations, such as cardiac arrythmias, myocardial infarction, and pneumonia are frequent. However, several complications are unique to
esophagectomy. An esophageal leak carries the highest mortality rate of any complication. An asymptomatic leak that is detected on a routine barium swallow and appears to
drain back into the esophageal lumen will usually heal without intervention. However,
larger, uncontained leaks require adequate drainage either by an interventional radiology
catheter, chest tube, or open drainage. Signs of sepsis will appear in conjunction with a
leak that is not adequately drained and indicate that thoracotomy with drainage of the
chest and decortication of the lung will be required. Endoscopy is useful to determine the
viability of the stomach and size of the leak. Small, well-drained leaks will often heal if
the lung is well expanded and there is no local sepsis. However, if there is extensive
necrosis, often the safest plan is resection of the conduit and creation of a cervical
esophagostomy. Graft necrosis, caused by infarction of the gastric tube, is a very rare
complication that may be fatal.
Other complications may not be apparent for several months postoperatively. An
anastomotic stricture is often related to a prior leak or vascular insufficiency at the tip
Chapter 1 / Esophagectomy and Reconstruction 13
of the gastric tube. Fortunately, the majority of patients respond well to periodic esophageal dilatation, and this is rarely required beyond the first postoperative year. Delayed
gastric emptying is an uncommon complication that can usually be managed conservatively. Common causes of delayed gastric emptying include the lack of a pyloric drainage procedure, obstruction at a tight hiatus or a redundant intrathoracic stomach.
Repeated endoscopy and balloon dilatation of the pylorus in conjunction with promotility
agents such as metoclopramide and erythromycin are usually sufficient. Finally, reflux
is a common problem after a gastric pull-up. It appears that the level of severity will vary
inversely with the level of the anastomosis. Anastomoses above the azygous vein have
a lower incidence of reflux than those below the vein. Symptoms of reflux are improved
by smaller, more frequent feedings, avoidance of liquids with meals, and avoidance of
recumbency after meals.
COST OF SURGERY AND FUNCTIONAL OUTCOME
As measured by both economic and psychological parameters, the cost of esopha-
gectomy is high. Currently, an uncomplicated esophagectomy will require several hours
of operating room time, and an average of 8 d spent in the hospital. The average cost
incurred at our institution for this level of care is approx $30,000–$50,000. However, this
figure may be easily doubled if complications ensue.
Few long-term studies on functional outcome following esophagectomy have been
performed. In a longitudinal study evaluating more than 100 patients undergoing
esophagectomy, more than 60% of patients experienced some form of gastroesophageal
reflux and 25% of patients noted some degree of dysphagia. Despite this, the ability to
work, perception of health, and resumption of daily activities were no different at longterm follow-up than the national norm (31). Although both physicians and patients must
be aware that esophagectomy is a major undertaking, it may be performed safely and can
provide excellent treatment for several disorders of the esophagus, as well as acceptable
long-term quality of life.
SUMMARY
1. Esophagectomy is a formidable operation with a consistent mortality rate of 5% and
morbidity rate of 40% whether it is done through the diaphragmatic hiatus with or without
a thoracotomy.
2. The most common indication for this operation is potentially curable esophageal cancer, and the most common way that gastrointestinal continuity is restored is by pulling
up a tube constructed out of the stomach. However, a segment of colon can be used if
the stomach is not available, or the patient has benign disease and an expected longterm survival.
3. The most feared and lethal acute complication is a leak from the anastamosis; especially
a leak into the chest and mediastinum which carries a 50% mortality.
4. Several postoperative complications following esophagectomy need medical therapy.
These include strictures, which can be dilated, and gastric emptying problems and
reflux symptoms.
5. Whereas extending the lymph node dissection during esophagectomy for cancer may
increase survival in very experienced centers, it is also clear that esophagectomy is a poor
palliative option for obviously incurable esophageal cancer.
14 Kent, Port, and Altorki
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